Make a Referral

"*" indicates required fields

*Please use Microsoft Edge, Google Chrome, or Mozilla Firefox browser to access this form. For additional support email helpdesk@principle-it.com.

Instructions

Please fill out the form below along with any additional information as appropriate. Send any demographics, H/P, DC Summaries, and medical documentation with the patient's name in the subject line to referrals@cardinalhospicecare.com or fax to 910-989-2691. Alternatively, you can download the form here to email or fax. We will forward to the physician for signature.

Response time

If you have not heard from us within 30-minutes during normal business hours, please give us a call to verify receipt. For urgent referrals sent after business hours, please call our toll-free number and the on-call team will assist you as soon as possible.

Patient Name*

Date of Birth*

Patient Phone Number*

Date of Last Physician Visit

Attending Physician/PCP

Physician's Phone Number

Primary Insurance & Number

Primary Diagnosis Associated with Referral

Referral Provider Name

Referral Provider Phone Number*

Referral Provider Email

Additional Information

Check here if you are emailing any supporting documents to referrals@cardinalhospicecare.com. If so, be sure to include the patient's name in the subject line.

Check here if you are faxing any supporting documents to 910-989-2691. If so, be sure to include a cover sheet with the patient's name.

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